Assessment of Mode of Anger Expression in Adolescent Psychiatric Inpatients

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ABSTRACT

Anger can play an important role in depression and suicide risk among adolescents. The present study evaluated internalized and externalized anger in 92 adolescent psychiatric inpatients. Results indicated that adolescents who internalized their anger were more likely to be depressed and to experience feelings of hopelessness. In addition, adolescents who internalized their anger made more serious suicide attempts than did those who externalized their anger. In contrast, adolescents who externalized their anger were more likely to have alcohol-related problems. Thus, different modes of anger expression appear to be related to different manifestations of psychopathology. It was concluded that assessment of mode of anger expression in adolescents may enhance our understanding of suicide and its risk factors.

There is a strong empirical link between depression and suicide. However, the relationship between depression and suicide appears to be complex and includes other negative emotions. The severity of depression has been found to be positively associated with levels of hostility and anger (Riley, Treiber, & Woods, 1989). In a retrospective chart review, depression, anger, and impulsivity were the most predominant characteristics reported among adolescent suicide attempters (Withers & Kaplan, 1987). In addition, a 3-year longitudinal study (Myers, McCauley, Calderon, & Treder, 1991) found that the experience of anger was a major variable in the prediction of later suicidality. Thus, the assessment of anger may play an important role in understanding adolescent suicidal behavior.

Despite its importance, anger has been a difficult construct to assess. Many investigators have quantified levels of anger based on either subjective means of assessment (e.g., Gispert, Wheeler, Marsh, & Davis, 1985) or retrospective chart reviews (e.g., Withers & Kaplan, 1987). Only a few studies have used psychometrically reliable measures of anger (e.g., Johnston, Rogers & Searight, 1991; Maiuro, O'Sullivan, Micheal, & Vitaliano, 1989). Another confound involves difficulties differentiating internalized anger from behavioral signs of depression. In fact, in a study designed to assess hostility and depression in relation to violent behavior in three groups of males (assaultive, suicide attempting, and nonviolent), a positive correlation was found between covert anger expression and depression severity (Maiuro et al., 1989). However, other research has supported the distinction between covert anger and depression (Johnston et al., 1991). Thus, mode of anger expression is an important component of anger assessment.

Anger can vary in its mode of expression (Spielberger, 1988), that is, the manner in which anger is manifested in different individuals. Externalized anger is expressed outwardly, toward people or things in the environment (e.g., assaulting or striking others, making verbal threats, using profanity profusely), whereas internalized anger is suppressed or directed inwardly (e.g., seetning or becoming agitated).

Aggression is a common manifestation of anger (Averill, 1983), and it is also related to suicide. One study (Cairns, Peterson, & Neckerman, 1988) found that suicidal adolescents did not differ from nonsuicidal, aggressive adolescents in terms of severity of aggressive acts, implying that many aggressive adolescents are at risk for suicide. Another study (Pfeffer, Plutchik, & Mizruchi, 1983) identified associations between suicide attempts and aggression in children.

Externalized anger may also be related to other forms of psychopathology, such as substance abuse (Milgram, 1993). Further, alcohol abuse has been found to be a very strong predictor of suicidal behavior (Pfeffer et al., 1988). In addition, substance abuse has been found to be more closely associated with suicide attempts than with suicidal ideation in children and adolescents (Kosky, Silburn, & Zubrik, 1990; Hoberman & Garfinkel, 1988). …